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1 Coventry Advantra (HMO) Teachers Retiree Insurance Program January 1, December 31, 2015 (a Medicare Advantage Health Maintenance Organization (HMO) offered by Coventry Health Care with a Medicare contract) This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Coventry Advantra (HMO)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Coventry Advantra (HMO) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on for plans that are not covered by the Teachers Retiree Insurance Program.. If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Sections in this booklet Things to Know About Coventry Advantra (HMO) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits This document is available in other formats such as Braille and large print. For additional information, call us at Y0022_2015_H2663_810_TRIP Accepted 9/2014

2 Things to Know About Coventry Advantra (HMO) Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Central time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Central time. Coventry Advantra (HMO) Phone Numbers and Website If you are a member of this plan, call toll-free If you are not a member of this plan, call toll-free Our website: Who can join? To join Coventry Advantra (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, live in our service area and be eligible for retiree health insurance through the Teachers Retiree Insurance Program. Our service area includes the following counties in Illinois: Adams, Bond, Boone, Brown, Bureau, Calhoun, Cass, Champaign, Christian, Clinton, Coles, Cumberland, De Witt, DeKalb, Douglas, Ford, Fulton, Greene, Jersey, Kendall, Lee, Logan, Macon, Madison, Marshall, Mason, McLean, Menard, Monroe, Morgan, Moultrie, Ogle, Peoria, Piatt, Pike, Randolph, Sangamon, Scott, Shelby, St. Clair, Stark, Stephenson, Tazewell, Vermilion, Washington, Winnebago and Woodford. Which doctors, hospitals, and pharmacies can I use? Coventry Advantra (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider directory at our website ( You can see our plan's pharmacy directory at our website ( Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or, call us and we will send you a copy of the formulary. 2

3 How will I determine my drug costs? Summary of Benefits Report Our plan groups each medication into one of three "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage. 3

4 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? How much is the deductible? Is there any limit on how much I will pay for my covered services? Covered Medical and Hospital Benefits Please contact your retirement system for plan premium information. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $3,000 for services you receive from innetwork providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and costsharing for your Part D prescription drugs. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Acupuncture and Other Alternative Therapies Ambulance 1 Chiropractic Care Dental Services 12 Diabetic Supplies and Services 1 Not covered In-network: You pay nothing. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $20 copay Diabetes monitoring supplies: 0-4% of the cost, depending on the supply Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 4% of the cost Diabetic supplies and sevices are limited to specific products and/or brands. Prior authorization is required for non-lifescan monitors and testing supplies, test strips (any brand) in excess of 100 strips every 30 days, and monitors (any brand) in excess of one monitor per year. 4

7 Preventive Care (continued) Hospice HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Part D covered immunizations are only covered at participating pharmacies under members Part D benefits. You pay nothing for hospice care from a Medicare certified hospice. You may have to pay part of the cost for drugs and respite care. Our plan will reimburse members for hospice expenses not covered by Original Medicare. You pay nothing for up to 12 months of hospice. Inpatient Care Inpatient Hospital Care 1 Inpatient Mental Health Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. $250 copay per stay For inpatient mental health care, see the "Mental Health Care" section of this booklet. Skilled Nursing Facility (SNF) 1 Our plan covers up to 120 days in a SNF per benefit period. You pay nothing No prior hospital stay is required. Prescription Drug Benefits How much do I pay? For Part B drugs such as chemotherapy drugs 1 : You pay nothing Other Part B drugs 1 : You pay nothing Deductible Initial Coverage No deductible You pay the following until your total yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. 7

8 Initial Coverage (continued) Retail Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Preferred Brand) Tier 3 (Non- Preferred Brand) One Month Two Months Three Months $10 copay $20 copay $20 copay $20 copay $40 copay $40 copay $40 copay $80 copay $80 copay Mail Order Cost Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Preferred Brand) Tier 3 (Non- Preferred Brand) One Month Two Months Three Months $10 copay $20 copay $20 copay $20 copay $40 copay $40 copay $40 copay $80 copay $80 copay If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy and pay the same as an in-network pharmacy, but you will get less of the drug. Coverage Gap Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2,960. After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you. 8

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